Provider Demographics
NPI:1659340198
Name:DVORKIN, TERRI J (APRN)
Entity Type:Individual
Prefix:
First Name:TERRI
Middle Name:J
Last Name:DVORKIN
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 WATERBURY RD
Mailing Address - Street 2:STE 300
Mailing Address - City:PROSPECT
Mailing Address - State:CT
Mailing Address - Zip Code:06712
Mailing Address - Country:US
Mailing Address - Phone:203-758-0878
Mailing Address - Fax:203-758-0877
Practice Address - Street 1:166 WATERBURY RD
Practice Address - Street 2:STE 300
Practice Address - City:PROSPECT
Practice Address - State:CT
Practice Address - Zip Code:06712
Practice Address - Country:US
Practice Address - Phone:203-758-0878
Practice Address - Fax:203-758-0877
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2011-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT001762363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
400001762CTOtherBCBS
500000696Medicare ID - Type Unspecified
400001762CTOtherBCBS